RESOLVE

Date:

Referral Source:

TUSLA
GP
Resource Centre

For Resource Centre, please specify:

Referrer Name

Referrer email address

Referrer Phone Number

Referral Type:

Individual Counselling
Couples Counselling
Family Counselling
Children's/Adolescent Counselling
Play Therapy
Other

If other, please give detail:

Reason for Referral:

Level of Counsellor Preferred (subject to assessment)

Trainee
Pre-Accredited
Fully Accredited

Payment by

Client
Subsidised
Organisation

Client Contribution (if applicable)

Client Information (Person to be contacted regarding this referral)

Name:

Is this person

The client
Parent
Guardian
Social Worker

Name and Age of Client:

Phone:

Email:

How would they rather be contacted

Phone
Email
Either